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S 1�� APPLICATION FOR SANITATION PERMIT Permit No. y (Complete in Duplicate) j! ate Issued - � S Applica}ion is hereby made to�tlie'San Joaquin Local Health District for a permit to const ucf and install the work herein described. This application is,made._in compGa.nc witb County Ordinance No. 549. ; VC-3 J6 ADDRESS AND L ATION_ - � ° --- ----- - ------- - � - -�-� ------- - ---------- -----Owners Name__ � Phone- `- Address_ Contractor's Name •--------•--- __- -------•--------- ------ Phone--r�---t7fc-d ._.. Installation will serve: Residence Apartment House' [.:] Commercial f❑ Trailer-ICour# E] Motel L] Other ❑ Number of living units: ___ --__ Number of bedrooms ---- Number of baths ._- _ Lot'size ---- Water Supply: Publics stem f , pp y: y ❑ Community system'❑ Private ��Depth`to,Watet Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ©"-Clay Loam ❑ Clay ❑ Adobe[Hardpan 0' Previous Application Made: Yes 0 ,NoA�New Construction: Yes No ❑ TYPE OF INSTALLATIONI. -AND SPECIFICATIONS: W � :Y I _ I (No septic Tank or cesspool permitted if blicfsewer.is available within 200 feet.) Septi nk: Distance from nearest well- _-Distance,^rom foundation__- _ ___- lvateriaL No. of,compartments.__ -_ --------..____Size._v _2f•-_ __4z x_:___Liquid epth_5---r..._-__.._Capacity__ G-9 Disposal Field: Distance from nearest well_,!.-......Distance from found — ation__---.--Distance to nearest lob line____ [�~ Number of lines------/------- --- -- -----Length of each line___�C_'7...- =_'- - Width of trench--------- --- -rr rr Type of filter material___-_--/.._-- - Depth of filter material------l.�_ �-----Total length------- ----------------- Seepage ------------- - -- p g ''=E` is See a e Pit; Distance of nes rest well �inin materaanlcegom fpund5ize:nDia 7 ---�Distance to nearest lot line_-______s$.__--� I p _ t g. _ � meter--- -------Depth_x�_.,' Cesspool: Distance .from nearest well-------------------Distance from foundation,--------------------Lining material .. :❑_ -. ._ material--_____._ ____.___:-.______5:xe:,D ameter= Dept ' Liquid Ca acitYr•--: --------:_-_-_gal-s- ..--- - -: Privy: . Distance from nearest well__--_...___ -------------------------------- _Distance from nearest building_____________________________ ' ❑ Distance-to nearest lot line----- ----------•-�-�•- Remodeling and/or repairing (describe):---------- ---------------#---------------•---------- ; , ---••-------------------------------------;;r-------------------••------• 1 -•-- ---------- --------------•--•-------- f -• _-• ----------------------------- ------ ------------ .: - - . f - he�eby certify�th I ha a prepared this a plication and that t ------- f work will be done in accordance with San Joaquin County V`J ordinanc s, State laws an rules and regulation of #he.-San Joa n Local Health District. (Signed)_..... -'=-=`-- -- - -- ------------ '---------------------------- ,, rand/o ntractor) _ .. BY: ----- --- - - - - -{Title).:_ w ---- - � 4 (Piot plan, showing size of lot, location of system in r a - n to wells, buildngs, etc., can be placed on reverse side). _ t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----__..---------______________ Y-.- - --- ---------------------- DATE "� ----- ------ REVIEWED BY- - ----5 - -- ---------------- ©ATE--------- -- - ----------------------- L. BUILDING PERMIT ISSUED---•---•------------------h-------- -- Y -------------------- ------ DATE Alterations and/or recommendations----------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------•-------=---------•--------------- --------- ---------------------------- -------------------------- --------------------- ---------------------------------------------------------------------- -------------------•------------------•--- ----------------- --------------- -------• ------------------------------------ ----------------- --------------------------------- ----- ------•---•- ------------------------------------------------- - • • - FINAL INSPECTION D J•----------- --------- ----------- - .. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 WestOak Streef 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100